Dermal Fillers -- Some Tips

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

The Dermatology Journal Club (Elsevier) published a CME-related activity on "Achieving Optimal Outcomes with Dermal Fillers". It is reviewed two articles. The CME exam is available here, but I can't find the on-line publication of the journal. You will need to register to use the site, but it is free. The two articles are listed below under references. If you use dermal fillers, these articles are well worth reading. I reviewed several of the different fillers here. The results can be great as in the photo to the right (credit) when used properly.

Tips for both patient and doctor:

• All dermal fillers have the potential for complications.
• Appropriate filler and injection-site selection, correct injection technique, and appropriate patient selection will minimize most complications.
• Temporary side effects associated with all fillers include swelling, redness, itching, bruising, and mild pain.
• Patients should limit their expressions and normal facial movements for 3 days after injection.
• The face should also be protected from extreme cold postinjection (ie snowmobiling without facial protection).
• By 3 months, permanent implants will have assumed their final shape. Touch-ups can provide additional symmetry and correction at this point.

Early complications include

• Persistent erythema (long-lasting redness) is the most frequent early complaint. It is usually due to unintended intradermal injection. If the erythematous area is flat, then intense pulsed light (IPL) can be used to effectively reduce the lesion.
• Ridges along the injection site and superficial beading are due to superficial intradermal injection and generally appear within 2 weeks. Injected strands (in particular those in the nasolabial folds) can separate unless an attempt is made to minimize motion at the injection site for 3 days. Limiting motion will allow the implanted material to become encapsulated and prevent it from dislocating.
• Blanching after a particulate injectable indicates that a ridge may form later unless pressure is applied to the area to distribute the implant evenly.
• Nodules will often appear within the first 4 weeks. They are often due to superficial or improper technique or inappropriate injection location. They tend to be small, isolated, well encapsulated, and respond poorly to intralesional steroids. They may require excision.

Late complications include

• Hypertrophic scarring may occur in patients who are prone, but only if the substance is injected too superficially (intradermally).
• Late inflammatory reactions include localized redness, swelling, and paresthesias. These can occur years after injection in all but the temporary fillers. Treatment with IPL or intralesional steriods is frequently effective.
• Granulomas tend to appear 6-24 months after injection. They are true foreign-body reactions. They can occur despite proper injection technique. They are characterized by their late-onset rapid growth, inflammatory appearance, relatively large size, discoloration, and projections into surrounding tissues. They seem to appear simultaneously at all injection sites. They usually respond well to intralesional steroids.
  
• Steroid atrophy, depending on the dose, may occur in 5-30% of patients treated for chronic redness, nodules, or granulomas.

Recommended intralesional corticosteroids include

• Triamcinolone 20-40 mg
• Betamethasone 5-7 mg
• Methylprednisonlone 20-40 mg
• Betamethasone (0.5 mL) in combination with 5-fluorouracil (1.6 mL) and lidocaine (1 mL)
• Triamcinolone (10 mg/mL) with 5-fluorouracil

Intralesional steroid injections can be associated with secondary effects such as skin atrophy, treatment resistance, and risk of recurrence.

A few summary points from the second article:

• Some patients are better candidates for aesthetic volumizing with Sculptra than others, because they are better at making collagen.
• Ideal locations for Sculptra injection are the nasolabial folds or creases, marionette lines, cheek hollows, zygomatic arches, temporal depressions, and depressed, scarred areas.
• Some physicians also use Sculptra for lateral eyebrows and dorsal hand areas.
• Large areas, such as cheek hollows benefit from serial injections of very small volumes (0.1-0.2 mL or less) applied in a cross-hatched pattern. Advanced needle techniques such as fanning and retrograde tunneling using very small volumes work well in these areas. Specialized training and experience are necessary to utilize these techniques.
• Sculptra should not be used in the body of the lip. This site offers a high probability of having nodules or papules form. Injections into the glabella and forehead are not recommended because of the risk of necrosis with any particulate product in these areas.
• Nodule or papule development can be prevented by proper injection technique and appropriate identification of areas to be injected. Ice application postinjection may minimize bruising. A massage several times a day postinjection to the area can minimize papule formation.

REFERENCES
Treatment Options for Dermal Filler Complications; Aesthetic Surg J 2006; 26:356-365; Gottfried Lemperle MD, PhD and David M Duffy MD
Use of Sculptra in Esthetic Rejuvenation; Semin Cutan Med Surg 206; 25:127-131; Kenneth R Beer, MD and Marta I Rendon, MD